NC Hair Loss Center 1418 Aversboro Rd Suite 103 Garner, NC Phone

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Camron Douglas
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1 NC Hair Loss Center 1418 Aversboro Rd Suite 103 Garner, NC Phone Consent to Use or Disclose Information for Treatment, Payment, Health Care Operations, or other Uses Permitted Under HIPPA The Patient hereby consents to the use or disclosure of his/her individual Identifiable health information protected health information by NC Hair Loss Center in order to carry out services or payment operations. The Client should review our Notice of information Practices for Protected Health Information for a complete description of the potential uses and disclosures of such information, and the Patient has the right to review such Notice prior to signing this consent form. NC Hair Loss Center reserves the right to change the terms of its Notice of information Practices for Protected Health Information at any time. If we do change the terms of the Notice of Information Practices, a copy of the revised notice will be mailed to you. The Client retains the right to request that NC Hair Loss Center further restrict how his/her protected health information is used or disclosed to carry out services, payments or any care operations.nc Hair loss Center is not required to agree to such requested restrictions; however if we do not agree to the clients requested restriction, such restrictions are then binding on NC Hair Loss Center. At all time the patient retains the right to revoke the consent. Such revocation must be submitted to NC Hair Loss Center in writing. The revocation shall be effective except to the extent that NC Hair Loss Center has already taken action on reliance on the consent. NC Hair Loss Center may refuse to treat the Patient if he/she (or an authorized representative) does not sign this Consent Form (except to the extent that the Facility is required by law to treat individuals). If the client(or authorized Individual) signs the consent Form and then revokes consent NC Hair Loss Center has the right to refuse to provide further services to the Patient as of the time of revocation(except the extent that the Facility is required by law to treat individuals). NC Hair Loss Center will not mail or fax any client records without signed record release form. All records are to be requested in writing, signed by client. The records will be release to client only. Client will be responsible for forwarding records to third party. I have read and understand this information. I have received a copy of this form and I am the client or am authorized on behalf of the client to sign this document verifying consent to the above stated terms. Date: Time: AM/PM Print/Signature of Client

2 NC Hair Loss Center Financial Agreement Payment Policy Thank you for choosing NC Hair Loss Center to assist you with your hair and scalp care needs. We are committed to providing you with quality affordable care. Listed below is the Hair Loss Center financial agreement/payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided upon request. 1. Deposit required for appointments. Upon scheduling your appointment, a deposit of $50 is required to schedule consultation appointments. This deposit is held to reserve and security your consultation appointment. In the event you would need to reschedule. Please call the office to reschedule your appointment within 24hours of your scheduled appointment. Your deposit will be credited to your next appointment scheduled. In the event that a client no show/or cancel their appointment in less than 24hours. The deposit will not be credited or returned. 2. Insurance. At this current time we do not accept insurance. All services need to be paid in full at the time of visit. Prices will be discussed in full before rendering services. A $50.00 deposit is required for all consultations. The $50.00 will be credited towards your total bill. NC Hair Loss Center is committed to providing the best service to our patients. Our prices are representative of the usual and customary charges for our area. Thank you for understanding our payment policy. Please let us know if you have any questions or concerns. I have read and understand the payment policy and agree and abide by its guidelines: Signature of patient or responsible party Date

3 NC Hair Loss Center 1418 Aversboro Rd Suite 103 Garner, NC Phone: Patient Demographic Form Please print and complete ALL pages. This document is part of your permanent record. Patients Name: Last First MI Address City State Zip Code Phone: Home Phone Cell Phone Work/Ext Last 4 digits of social DOB Gender Martial Status Pharmacy Name: Phone Fax Address: Emergency Contact: Name Phone Relationship to client: Can we leave a message for you at your (check yes or no?)home: Yes No Work: Yes No Primary Care Doctor Name and phone Number: Specialist Doctor Information: Primary Hair Stylist/Barber Information:

4 NC HAIR LOSS CENTER 1418 Aversboro Rd Suite 103 Garner NC Name Date Medical History Form Your answers on this form will help your provider better understand your medical concerns and conditions better. This form will NOT be put directly into your medical chart. If you are uncomfortable with any question, do not answer it. Best estimates are fine in you cannot remember specific details. Thank You! AGE How would you rate your general health? Excellent Good Fair Poor Main reason for today s visit: Other Concerns I would like to discuss if there is time: REVIEW OF SYMPTOMS: Please (Check) any CURRENT Symptoms you may have. Fever/Sweats/weakness Cough/Wheeze Unexplained weight loss/gain Blood in bowl movement Change in Vision Nausea/vomiting Diarrhea Anxiety/Stress Difficulty hearing/ringing Hay Fever Chest pain nighttime urination Unusual bleeding unexplained lumps Depression headaches Rash Memory Loss History of hormone issues History of testosterone issues History of Thyroid issue Blood Disorder Vitamin Mineral deficiencies Currently taking any medicine Hypertension Diabetes

5 Arthritis/joint pain Asthma Child Birth Years In the past month, have you had little interest or pleasure in doing things or felt down, depressed or hopeless? Is there anything not listed that you would like for us to know? Last physical visit with any primary doctor(month and year) Lab Work SURGICAL HISTORY Please list all prior operations with dates FAMILY HISTORY: Please indicate the current status of your immediate family members: please indicate family members (parents, sibling, grandparents, aunt,or uncle)with any of the following conditions: Alcoholism Cancer, specific type Heart Attack Diabetes High Cholesterol High Blood Pressure Stroke Other: Other: SOCIAL HISTORY: Tobacco Use Cigarettes Never Quit Date Current smoker: Packs/Day #of years Other tobacco: Pipe Cigar Snuff Chew Are you interesting in quitting Alcohol Use Never Quit Date Is your alcohol use a concern for you Drug Use Do you use any recreational drugs?(if yes type) Have you ever used needles to inject drugs? Caffeine Intake None Coffee/soda/tea (average servings per day? Weight: Current BMI over weight average below weight

6 Diet: How do you rate your diet? Do you eat 4 servings of dairy or soy daily or take calcium supplements? Are you current taking any diet supplements? Are you currently dieting? yes or No? If yes, what does your diet consist of. Exercise: Are you currently exercising on a routing basis? how long how often?

FOLSOM CARDIOLOGY. Registration Form. Office Use Only: Patient Acct #

FOLSOM CARDIOLOGY. Registration Form. Office Use Only: Patient Acct # FOLSOM CARDIOLOGY Please complete forms in black ink only Registration Form Office Use Only: Patient Acct # Name: Date of Birth: Address: Street City State Zip Code Phone: Work: Cell: Marital Status: S